1. (a)

   1. (1) The primary purpose of documentation is to facilitate the counseling relationship by bringing into focus all the pertinent data about the individual.

   2. (2) This enables the counselor to:

      1. (A) Understand the individual;
      2. (B) Counsel and help plan future adjustment;
      3. (C) Help secure necessary medical, educational, and other rehabilitation services; and
      4. (D) Assist in locating suitable employment.

2. (b)

   1. (1) Proper documentation provides the information needed to establish a professional relationship with the individual.

   2. (2) During early contacts with the individual, the documentation should emphasize:

      1. (A) History;
      2. (B) Present adjustment and environmental situation; and
      3. (C) The objective measures of, or reports on, physical and mental capacities.
   3. (3) This provides an informational basis for the counseling relationship and provides substantiation for planned programs of services.

3. (c)

   1. (1) Documentation should be clear, objective, and limited to information that is significant and pertinent to the individual’s vocational rehabilitation needs.

   2. (2) Documentation should lead to a plan of action by including:

      1. (A) Evaluation summaries;
      2. (B) Work history;
      3. (C) Medical/behavior assessments; and
      4. (D) Other relevant resources.

4. (d)

   1. (1) The processing of work in accordance with existing policies and procedures is the counselor's responsibility.
   2. (2) Case processing, filing, reporting, and recording must be performed with extreme care.

   3. (3) Case documentation includes:

      1. (A) Agency forms;
      2. (B) Medical information;
      3. (C) Case narratives;
      4. (D) Post-operative reports;
      5. (E) Training reports; and
      6. (F) Other pertinent information related to the individual’s rehabilitation program.

Codification Notes: “ECF” means electronic case file.